The proportion of parents refusing vaccines has steadily increased over the past decades. Let’s stop debating whether refusing vaccines is safe and instead engage in examination of the factors that may make vaccine refusal safer.

I’d be roundly and appropriately condemned by pediatricians, immunologists and public health officials even though vaccine refusal has grown tremendously to affect as much as 20% of children.

There’s nothing subjective about the fact that homebirth with a CPM leads to preventable infant deaths.

Why?

Because we understand that vaccine refusal stems from lack of knowledge about how vaccines work or the dangers of vaccine preventable illnesses, and a fraud committed by Dr. Andrew Wakefield falsely connecting vaccines to autism. It is the responsibility of medical professionals to meet this knowledge deficit with accurate information, correcting myths and misapprehensions with scientific data.

We are also coming to understand that vaccine refusal is closely tied with privilege, defiance and a faux sense of empowerment. Nothing screams privilege louder than ostentatiously refusing something that poor women around the world are desperate to have. Anti-vax parents glory in defying authority, imagining that it marks them as “educated.” Similarly vaccine refusal is viewed by anti-vax parents as an empowering form of rugged individualism, marking out their own superiority from those pathetic “sheeple” who accept medical authority because they haven’t done “their own research.”

So why are some obstetricians insisting that we need to examine the factors that may make homebirth safer when it has risen from a fringe of a fringe practice (0.87% of births) to a fringe practice (1.5% of births)? That’s the terrible mistake made by Ellen L. Tilden, PhD, CNM; Jonathan M Snowden, PhD; Aaron B Caughey, MD, PhD; Melissa J. Cheyney, PhD, CPM, LDM in their Medscape commentary Making Out-of-Hospital Birth Safer Requires Systems Change.

They write:

… [O]ut-of-hospital births have steadily increased over the past decade, up 72% from 0.87% of US births in 2004 to 1.5% in 2014. This trend shows no sign of reversing; disengaging with the debate over whether out-of-hospital birth is safe and instead engaging examination of the factors that may make out-of-hospital birth safer is of critical import. Formally including home and birth center care in US maternity care systems will improve outcomes for the growing numbers of women seeking care outside of the hospital. In parallel, increasing the availability of physiologic birth in-hospital may decrease the number of women choosing out-of-hospital birth as a means of avoiding unnecessary intervention, with the added benefit of reducing iatrogenic maternal morbidity for the predominance of low- to moderate-risk women who choose hospital birth.

Why should we take that approach to a dangerous fringe practice when we would appropriately condemn pediatricians like Dr. Bob Sears who take that approach to vaccine refusal, a dangerous practice that is widespread.

I have deep sympathy for Dr. Caughey and his obstetric colleagues who are daily forced to witness the tragic outcomes of homebirths attended by CPMs, counterfeit midwives who can’t be bothered to meet the international standards for midwifery practice. Obstetricians are desperate to save the lives of babies endangered by incompetent practitioners, and mothers who have been fed a steady diet of mistruths, half truths and outright lies by the homebirth industry.

But American homebirth is MORE dangerous than vaccine refusal; an approach that attempts to straddle the homebirth fence is unlikely to address the deadly risk it poses.

Why?

Because homebirth, just like vaccine refusal, is based on misinformation, privilege, defiance and a faux sense of empowerment. CPMs are just like vaccine charlatans, spreading lies about the inherent dangers of childbirth, and encouraging potential clients to imagine themselves as smarter than and superior to the sheeple who merely follow the medical advice of their obstetricians.

The authors write:

What one deems “safe” is inherently subjective, involving a series of judgments and a relative weighing of multiple (and sometimes conflicting) factors.

That is spectacularly wrong! There’s nothing subjective about the fact that vaccines don’t cause autism and there’s nothing subjective about the fact that homebirth with a CPM does lead to preventable neonatal deaths.

There’s no more reason to validate homebirth advocates’ fanciful view that childbirth is inherently safe than there is to validate anti-vax’ parents fanciful view that vaccines cause autism.

There’s every reason, in fact, to meet misinformation with accurate scientific evidence, and to make it clear to mothers contemplating homebirth that it poses a serious risk to their babies.

The subjective issue is NOT whether homebirth with a CPM is safe; it isn’t. The subjective issue is how an individual balances the various risks and benefits to make her own choice. Some women may find any increased risk to the baby anathema, whereas some will find the increased hospital risk of C-section deeply problematic. It is the right and prerogative of women to make their own informed medical decisions. But accurate scientific data is required for informed decision making and it’s the ethical obligation of obstetricians to provide it.

Tilden et al. start their piece with a quote:

Birth is as safe as life gets. – Harriette Hartigan, direct-entry midwife

That is abject nonsense from a charlatan, no different from Andrew Wakefield’s contention that vaccines cause autism.

Health care providers MUST respect patient choice, but we MUST NOT pander to charlatans and their acolytes by validating lies. If we do, we won’t stop preventable deaths at homebirth; we’ll encourage them.

“Homebirth, just like vaccine refusal, is based on misinformation, privilege, defiance and a faux sense of empowerment.”

Another spot-on post addressing not just the problems caused by pseudoscience, but the motivations of the people who buy and sell it. Thanks!

Steph858

Unfortunately, Dr. Andrew Wakefield is entitled to his title of Dr. As it’s an academic title. To rectify the misunderstandings and injustice which may arise from this fact, I propose that one of the following qualifiers be appended prior to his title:

‘Disgraced’
‘Struck Off’
‘Quack’
‘Unethical’
‘Incompetent’
…

Any preferences/other ideas?

Nick Sanders

“Scum-sucking, fear-mongering charlatan”

Platos_Redhaired_Stepchild

“Criminal” because the b-stard belongs in prison!

sdsures

Meh, not strong enough.

demodocus

bought and paid-for?

demodocus

Isn’t he a genuine pharma shill from that original paper?

sdsures

Wakefield is not a licensed medical practitioner any longer. British medical terminology is a little bit different: we don’t have MDs here, we have MBBS. My “attending” neurologist (like Dr Mark Greene and Dr Kerry Weaver in “ER”), which is what he would be called in America, is here called a “consultant”, and has the title “Mr” before his name. So, it’s “Mr Zermansky”. He’s actually the top neurologist in Greater Manchester specializing in headaches and other neurological things; one of his other interests is Parkinson’s.

Basically, in the UK, you have 2 separate degrees that you complete to become a doctor. The model of UK medicine is slightly different. The history is different, too. Sorry, I know this is confusing! If I get any details wrong, please correct me. I had to swot all this up when I moved here from Canada.

Step 1) You get your medical degree: MBBS.
Step 2) You then get to be a junior embryonic doctor, which gives you the right to treat patients and figure out what specialty you want to be in.

There are doctors who do have a MD after their name, who have a doctorate, who have the courtesy title, which is granted when you fulfil the criteria to be licensed. It is an honorary title.

I vote to call Wakefield “F***stick”. He should have been sent down for assaulting all those poor children.

Hubby just informed me that Wakefield is putting “FRCS” after his name – Fellow of the Royal College of Surgeons – when he hasn’t paid his dues there to be allowed to use that acronym after his name SINCE 1995! BEFORE The Lancet 1998 article. He’s a very naughty boy!

Monkey Professor for a Head

I haven’t worked in the UK, but in Ireland (which takes a lot of cues from the UK) the title of “Mr” or “Ms/Miss” is reserved for consultant surgeons. I believe it’s a historical artifact, based on the differences in training that used to exist – surgeons initially being barbers.

sdsures

I remember something about barbers = surgeons. Are you a doctor yourself?

PS: When I was still receiving DHE (dihydroergotamine) for my severe migraines – it’s been replaced by Botox as a more effective outpatient treatment – in hospital, I was under the care of a lovely Irish-accented nurse. 🙂 Very pleasant to listen to, helpful when I was feeling particularly sick from the infusions. Thank god for Ondansetron. Even though they premedicate you before bringing on the DHE bag, there’s only so much they can give you and it didn’t always work. Bleargh. So, I’d do whatever I had to to make the nurse talk more, LOL.

Monkey Professor for a Head

Yes, I’m a doctor, although I’m on an indefinite career break at the moment to be a SAHM.

Thanks for the link, I always enjoy documentaries like this. The history of medicine is fascinating. The BBC did a great series on the history of surgery called blood and guts. The one on plastic surgery is amazing.https://youtu.be/Lk2v8BvIeTM

sdsures

I love documentaries of all types!

Marie Gregg

“Birth is as safe as it gets.”

That’s one of the dumbest things I’ve read in awhile. If I were to defy the odds and biology and somehow get pregnant, I would immediately be placed in the high-risk category. Nothing about my body makes pregnancy or birth safe. What kind of magical world do these people live in?

FormerPhysicist

War is as safe as life gets? It makes as much sense.

sdsures

Maybe we’re not inhaling enough fairy dust?

The Computer Ate My Nym

increasing the availability of physiologic birth in-hospital

What exactly does this mean? I admit it’s been a long time, but when I was in medical school, a woman who was in labor, dilating nicely, and not requesting any intervention such as pain relief would simply be monitored once in a while and asked if she needed anything. I don’t recall there being any mandatory interventions except for maybe a saline or hep lock IV in case of emergencies. So how is “physiologic birth” unavailable in hospitals?

Margo

Measle outbreak in North Island NZ, three schools closed and only reopening to those students who can prove in writing that they have been immunised. This is very serious and yet air time was given to an anti vaccinator who suggested the situation not that baD….absolute madness.

MWguest

I. Love. This.

sdsures

“”Birth is as safe as life gets.” ~Harriette Hartigan, direct-entry midwife”

The photographer is probably less dangerous at homebirth since they wouldn’t presume to advise on progress and no one would listen to them if they did.

sdsures

Guess she calls herself whatever she thinks she can get away with. At least the professional togs I have known have the extensive educational background and certification to show for it.

Platos_Redhaired_Stepchild

I read that and thought clearly these people have never watched a nature program on tv in their lives if they think “life” or “nature” is safe. A couple of episodes of NOVA or Nat’l Geo should disabuse them of that.

momofone

But don’t you know–“nature” is warm and fuzzy–puppies and kittens and bunnies!–and it just wants everyone to get along!

The Computer Ate My Nym

Puppies and kittens aren’t nature, they’re domesticated. Bunnies, well, nature is bunnies starving because they can’t get enough milk and getting eaten by predators. Including puppies and kittens. And toddlers, if it comes to that.

J.

Bunnies also get eaten by their mother if she senses danger. That way she can re-absorb those calories and expend them on a new litter when things are safer.

momofone

I had a cat once whose mother chewed off his leg because something was wrong with it. I am so glad for modern medicine. I don’t think I’m cut out for chewing off defective body parts.

sdsures

They didn’t mention that in “Watership Down”.

sdsures

I love those shows where creatures fight for survival and eat each other!

Mattie

Over the summer, a stray cat gave birth to 4 kittens in the garden, no issues, all babies were healthy and are growing nicely 🙂 she had no ‘prenatal care’ and likely hasn’t had vaccinations or anything, she also gave birth to two kittens last year that are still healthy. If I was using that as my example then sure birth is super safe….unfortunately a few weeks later one of the kittens from last year gave birth to 5 kittens, all stillborn. Birth is not easy, inherently safe or predictable.

For anyone curious, the kitten who had the stillborns is now helping to nurse and mother the 4 living babies 🙂

Irène Delse

Looks like young age at first birth is not better for cats that humans. Or maybe it was some genetic anomaly. Or one of the diseases that domestic cats are supposed to be vaccinated against. (A sick mother is often at risk of losing her babies even if she herself survives.)

Of course, cats are so successful at reproduction that most responsible cat owners neuter or spay they pets…

Mattie

Yeh 🙁 I told my dad to neuter the mother cat and kittens last year, he didn’t…then got angry that they had 4 more kittens. The town they live in has an out of control cat population and the local government is doing NOTHING to help. They could subsidise the cost of neutering or offer a catch/neuter/release program, but they don’t 🙁

sdsures

🙁

Mattie

Pretty much, it broke my heart that she’d got pregnant and lost the babies, even though kittens are lovely they’re expensive and there are so many unwanted cats everywhere 🙁

sdsures

In cats and otters, first litters can often result in either stillbirths or the death of the entire litter, simply becuase in otters, the parents have no idea what they’re doing.

Otter parents have to teach the babies EVERYTHING: cleaning, preening, holding their breath underwater (mother otters will dunk and hold their babies underwater to teach them this).

Our 2 housecats are spayed and neutered, but nonetheless we have a persistent, lovelorn intact male (whom we named Cicero) wanting to make friends with all of us. We actually petted him a couple days back, and hopefully at some point we will be able to get him to the vet to see if he’s chipped, and see if we can have him neutered.

Juana

Well, that’s true – kind of…
Life is not exactly safe in many ways, especially when you don’t live in the first world. That’s why we strive to MAKE it safer. Duh.

jsterritt

I didn’t read this quote as Hartigan implying that birth is safe, but as her excuse for when an unnecessarily more unsafe DEM-assisted homebirth yields tragic results. This is in keeping with the false narratives these practitioners (and their smarter-than-science clients) invent to sleep at night — e.g., a preventable neonatal death was a “journey” rather than negligence.

guest

“The subjective issue is how an individual balances the various risks and
benefits to make her own choice. Some women may find any increased risk
to the baby anathema, whereas some will find the increased hospital
risk of C-section deeply problematic. It is the right and prerogative of
women to make their own informed medical decisions.”
Quite, Dr Amy. Well said.
And given that there women who DO decide that the increased risk of C-section & forceps associated with hosptial birth is one they don’t want to take one, don’t we owe it them to make HB safer?

Anon13

Homebirth is a safe as it can be with well qualified CNMs who risk out appropriately, have solid transfer plans and hospital privileges and OB back up. And a “Respect Birth” attitude. This is an available choice and Dr. Amy has never spoken out against it, provided the mother has complete informed consent.
The problem continues to be dangerous lay midwives who do not risk out, do no screenings for risks, and have no idea what to do in an emergency.
A final point. How many of mothers would choose homebirth when knowing that there is significant chance of demise and brain injury to the baby? I think it would still be a fringe population if the risks were well known, transparent, and there was no shame in a C-section.

Amazed

Yes, of course. That’s what Dr Amy is doing. I can’t imagine a better way of making homebirth safer than weeding the unprepared practitioners, aka CPMs, out.
However, telling women who want homebirth that homebirth is safe and/or safer than hospital birth is where I draw the line. It isn’t making homebirth safer, it’s lying to them or stroking their ego, telling them they’re making a good and safe decision, depending on what they truly know about the risks involved.

Roadstergal

If a woman doesn’t want a C-section or forceps, she can decline either in the hospital.

She simply doesn’t have access to them at home. Or to much of the monitoring that would allow her to see they might be indicated and allow her to make that call.
So homebirth is a way of lying to women by omission. Rather than making informed decisions, she is railroaded into them.

Hell of a way to do health care.

KeeperOfTheBooks

Or a combination of omission and ignorance.
A friend of mine is in the process of becoming a CPM. We’ve tacitly agreed not to discuss matters pertaining to childbirth, babies, medicine, et all beyond “congrats on the new baby, he/she’s adorable!” because, bluntly, on the rare occasion we’ve had discussions about this sort of thing, her response to facts and statistics is “I’m no longer comfortable with this discussion, so we need to stop.”
This is someone who genuinely means well, but given a combination of her background (religious fundamentalist, OBs just want to cut and sterilize you for their own convenience, God wants you to birth vaginally, the lot) and her lack of education (home”schooled,” and I use the term in the loosest possible sense), she’s a string of dead babies waiting to happen. The woman thinks the Rhogam shot is bad cos it isn’t natural; she rejects all vaccines because if you just eat healthy enough, diptheria’s not a problem; Group B strep, giant babies, and gestational diabetes are, like footling breech babies, a variation of normal…the lot. She genuinely thinks she’s going to do good by being a midwife and saving women from teh ebil OBs. Problem is, of course, she isn’t: she’s so incredibly ignorant, but doesn’t know it, because she’s very well-educated by her community’s standards. Her community, of course, consists of people who never went to college, were primarily home “schooled” as well as she was (i.e., not), and since she has an active and curious mind, she’s very well-educated in the woo. Icing on the cake is that being a CPM is really the only way that she’ll be “allowed” to pursue more education; going to nursing school, for example, would be seen as neglecting her family.
Sorry, that turned into a ridiculous rant. Have I mentioned that I hate this crap? I really, really do.

sdsures

“If a woman doesn’t want a C-section or forceps, she can decline either in the hospital.”

Does she want a dead baby?

sdsures

“…allow her to see that they might be indicated…” Where did she get her medical degree from?

swbarnes2

The #1 way to make it safer would be to insist on rigorous risking out procedures, (including EVERY woman who hasn’t had a successful vaginal birth) transfer to hospitals at the drop of a hat, and to make it illegal for anyone to call themselves a midwife without at least meeting international midwifery guidelines.

None of those are acceptable to the homebirthing midwife community. All of that is absolutely contrary to their ideology, which is that childbirth is easy and safe for every woman.

Who?

No.

If they don’t want a forceps or a cs, that is their choice. They can insist on that choice even as their baby dies inside them. They can insist on it in hospital.

Over and over we see women adamantly opposed to ‘intervention’ agreeing to appliances, surgery and pharmaceuticals to save themselves when their baby is already dead due to their appetite for risk and failure to take advice from medical professionals rather than birth hobbyists.

Quite apart from that ideological objection, healthcare is a finite resource. From where in the health system should money be pulled to fund a fashion choice that will always be less safe than the mainstream?

Petticoat Philosopher

I’m confused by the fact that “homebirth” is being automatically equated to “homebirth with CPMs” when Dr. Tuteur just recently wrote about the Canadian and Dutch healthcare systems, in which homebirth midwives are required to actually be qualified and to have hospital admitting privileges and where homebirth is apparently much safer. Since the authors choose to quote a “direct entry midwife,” it seems that that is, unfortunately, not what they’re proposing but isn’t it a pretty good counter-proposal?

Don’t get me wrong, I still would never choose homebirth. It can’t ever be as safe as having a medical team right there in case something goes wrong quickly. Plus, I just don’t understand why anyone would ever want to do anything as messy as give birth in their own home. Hell, no! If and when I give birth, I want to do it in a nice, neat place that will be cleaned before and after me by people who are not me and where I can labor without thinking things like “Damn, I really do need to caulk that corner of the baseboard.” But if some women are going to choose homebirth, doesn’t it make sense to actually regulate it so that it is overseen by real medical professionals who are connected to local medical facilities? Other countries have demonstrated that homebirth actually can be made pretty safe, even if it’s not quite as safe as hospital birth (or birth-center-on-the-campus-of-hospital-birth) so shouldn’t we at least shoot for that?

MaineJen

We do have the equivalent of Canadian and Dutch midwives…they’re called CNMs, and they’re very highly qualified. Most of them won’t attend home births because they understand the risks involved and don’t want to take on the liability.

Petticoat Philosopher

Yes, I am familiar with CNMs and am aware that most don’t want to go anywhere near homebirth. Which makes me wonder, what is different in Canada, where homebirth is more common and qualified midwives (the equivalent of CNMs, although I think their cert has a different name) are the only legal option? That’s a real question to which I honestly don’t know the answer. Is it because they have to have admitting privileges so they are just more linked into the system? Is it our hot mess of an insurance system vs. Canada’s single-payer system that makes it just that much more complicated and baroque?

It seems like a good start would be to do the same things here–legally require all midwives attending homebirths to be CNMs and require them to have admitting privileges. Get rid of CPMs. And I guess I’m just confused because that seemed to be exactly what Dr. Tuteur was calling for in her NYTimes piece. It won’t make homebirth ideal but it will go far to prevent women from being duped by quacks with made-up credentials.

Who?

A couple of thoughts.

Making something illegal won’t stop it happening. And for an element of the homebirth community, fighting against ‘the man’ is part at least of their story. So doing as you suggest would drive those women even further into the arms of the homebirth hobbyists.

Women who are scared of hospitals will still choose to stay away. Should hospitals work hard to encourage people to use their services? Yes. Is it wise to encourage a sub-standard replacement? No.

I worry about the finances of it too. Money is scarce in healthcare. From what care/treatment should the money come to fund the CNM homebirth environment you propose?

Petticoat Philosopher

I think you’re right about some of the women being pushed further into the arms of the homebirth hobbyists but not all. Some women are more dyed-in-the-wool anti-medicine, anti-science nuts than others. I find that you tend to find two groups among alt-med types. Those who actually believe that the science supports their views and those who just think that science is an evil conspiracy by “The Man,” and who cares what it says? The first group is more likely to be taken in by bogus credentials that lend an air of legitimacy to total incompetents. They’re more likely to use the existence of those credentials, and the fact that they are legal, to try to convince themselves and others that their choice must be safe. After all, if it weren’t, then why would these certifications exist and be legal?

The second group are the tinfoil hat wearers that place no stock by any “system,” at all, whether it’s the medical system, the legal system, the government, whatever. So yeah, they won’t care if CPM births are illegal. They’ll wear it as a badge of honor. There’s nothing you can do about them.

But I think that is a smaller group than people who generally believe in being law-abiding (and for whom the concept of something being illegal does carry some weight) and generally believe in the idea of science and medicine but just don’t really understand what it’s all about. I do think that choosing an uncertified midwife who is practicing illegally under the radar probably would be a bridge too far for a lot of these women, whereas choosing a midwife who is completely legal and has fancy letters after her name and everything would not be.

You can’t do anything about the tinfoil hat crowd. You can’t fix stupid and there isn’t any law in existence that some people don’t break. But that doesn’t mean there’s no point to having laws.

And I share your concern about finite resources but, by your argument about eliminating CPMs driving women further into woo, wouldn’t eliminating homebirth altogether do that even more? If hospital birth is the only option, how would that not also drive possibly even more women into unsafe choices? Let’s be clear here, I’m not “proposing” anything. I’m just thinking out loud about how best to reduce harm to women. I’m not making CNM homebirth into some kind of hill to die on. I don’t know how it would work and I don’t pretend to. I’m just looking at examples of other countries (as Dr. Tuteur did) that have better health outcomes than we do here in the US and asking “What are they doing differently and is it feasible or desirable to implement it here?” The answer might be “no on both counts” for all I know, but it seems worth asking because Dr. Tuteur herself made the comparison.

Who?

We can all agree it’s complex.

In the end, we can’t ‘eliminate’ homebirth-babies do sometimes have a way of turning up unexpectedly, and no one wants to get into a space where women with precipitous labour, or someone who doesn’t understand how far along they are, is penalised for birthing at home instead of hospital.

As for ‘better outcomes’, they are always worth working towards. But for a subset of women, no option that involves ever being in hospital will be good enough, though they may want that option in the heat of the moment, or for themselves after their baby has died or been injured. And I think in both the UK and Canada, even with their strict regimes, homebirth is less safe for baby than hospital birth. How we weigh baby’s outcomes-the baby is the volunteer in this excursion-against mother’s aspirations for herself is another whole question.

Daleth

Making something illegal won’t stop it happening.

No, but it will certainly reduce it. And when you’re talking about home birth, that will save lives (and brain function).

Roadstergal

“homebirth is apparently much safer”

Safer than homebirth in the US – but less safe than hospital birth.

We’ve discussed the paper that demonstrated that a high-risk Dutch woman under OB care has better outcomes than a low-risk Dutch woman under midwife care, and now we have preliminary data showing that a reduction in home births after stricter risking-out criteria has decreased perinatal mortality. No matter which way you slice it, running away from judiciously applied monitoring and medical technology is not going to end well overall.

swbarnes2

I think you mean that “high risk” cases have BETTER outcomes than the HB’ers.

Roadstergal

Oops, yes, too much multitasking. 🙂

Petticoat Philosopher

Good thing I never advocated for that.

But the result of Canada’s the Netherlands’ approach to homebirth does seem to be that outcomes for women and babies are better than they are for American women. I never actually said that homebirth under the most optimal conditions is as safe as hospital birth. I actually very explicitly contradicted that view in my OP. But it doesn’t seem like there can be any downside to regulating homebirth in the US to make it safer, even if it can never be made as safe. And I was really just trying to get some clarity because that seemed to be what Dr. Tuteur was advocating for her in NYTimes piece. We can’t make women choose the safest option but we can make sure that the less-safe options aren’t downright reckless.

I’m literally just trying to figure out what Dr. Tuteur’s position actually is because I’m interested.

swbarnes2

Measured how? You can search for articles on the Dutch system here, their perinatal stats are NOT better than other European counterparts.

Petticoat Philosopher

I never said they were. But they’re apparently better than ours here in the US and that’s the country we’re talking about, not other European countries.

The neonatal death rates are also similar. Data from 2011 shows that the Netherlands has a neonatal death rate of 3/1000 births while the US rate is 4. http://chartsbin.com/view/1451

Maternal mortality rates are complicated by the lack of healthcare access in the US and our racial diversity (much greater than the Netherlands).

swbarnes2

You understand, the way to make homebirth safer is to do fewer of them. That’s how every country that has better stats than the US does it. Tell more mothers “no homebirths for you, too risky”. Tell more mothers “your labor is not going perfectly, you need a hospital now”.

You can’t, say, give Jill Duggar more drugs to use on patients, or a home vacuum system, or forceps, and expect better outcomes. You can’t make Jill Duggar proficient in infant resusitation, even if you mandated that she carry a lot more equipment for that purpose. If she WANTED to be good at that stuff, she’d go to nursing school. Homebirthing midwives are swimming in an ideology that says they work BETTER with knowing and doing less.

Homebirth will be safER when it is taken away from the hobbyists. There is no positive way to do it, just the way of taking it away. But the hobbyists aren’t going to give it up without a fight. And every woman who buys their ideology of “Bad things only happen to bad women” will fight too.

Petticoat Philosopher

No, we make homebirth will be safER by taking it away from the hobbyists.

Oh, for Christ’s sweet sake, you do understand that taking birth away from the hobbyists was exactly what I was suggesting, right? I am not suggesting that we just give Jill freaking Duggar more tools and pat her on the the back. I was saying “Wouldn’t it be an improvement if we got rid of CPMs (like Jill Duggar) and required that only CNMs attend homebirths?” I was saying pretty much exactly what Amy said in her NYTimes piece. I never said homebirth was as safe as hospital birth, even under the best conditions. I said “It would probably be a good idea to make the most dangerous options illegal.” (And that would incidentally probably cause there to be fewer homebirths because fewer women would be taken in by incompetent amateurs with serious-sounding but bogus letters after their names!) And I only said that because I was trying to get some clarity on Dr. Tuteur’s position because she appeared to be saying, in no uncertain terms, that eliminating the CPM credential and making sure any midwife who attends a homebirth is actually legit would be a good thing to do. Which is pretty hard to argue with.

You appear to want a flaky homebirth idealogue to argue with. I’m sorry to say that that person is not me. I have repeatedly asserted that hospital birth is the safest option. There are loads of militant crunchies on the internet who actually hold the views you are attributing to me who would be happy to argue with you. I don’t see why you need to tear down strawmen with me.

Bombshellrisa

There are plenty of CNMs who are woo filled. I would feel better if the “only CNMs can attend home births” rule with a few strings attached: must be licensed, carry malpractice insurance, have hospital privileges and OB back up.

Petticoat Philosopher

Yeah, that sounds pretty reasonable to me.

I have heard that the minority of CNMs who do do homebirths are more likely to be woo-filled. Of course there is unfortunately no credential or education level that can completely prevent that–as evidenced by the existence of MDs who are equally woo-filled. (In some cases these doctors appear to just be morally bankrupt opportunists who want to make a buck. But, frighteningly, some of them appear to be True Believers too.)

Bombshellrisa

It’s interesting how that works. The practice of OBs that I saw with my son are rather wooish and deliver at a hospital trying to become baby friendly. What alarmed me was that instead talking to someone about proven meds that can help postpartum depression, the doctor fed into the woo and suggested exact dosages of certain herbs to take.
There are CNMs who deliver in the hospital and make the “not all homebirth midwives” argument for their CPM friends, and you still see them standing together in sisterhood as midwives. That makes it much harder for safe home birth practices to be established, which hurts everyone. I am always shocked how many well educated, well trained CNMs are willing to stand up for their sister midwives who are at most CPMs.

FormerPhysicist

Ridiculous malpractice. One cannot, absolutely cannot, take exact dosages of specific herbs. If you grow and dry the plants yourself, potency varies. If you buy supplements off the shelf – it doesn’t matter how they are labeled. There is no quality control, and it’s very uncertain what dosage you’ll get, or even if you get that herb.

And included with “must carry malpractice insurance”–implicitly, since insurers won’t cover you without it–is “must strictly adhere to risking-out protocols such as no breech, no VBAC, no multiples, no GD or pre-e, no women with a history of PPH or shoulder dystocia, etc.”

Bombshellrisa

Exactly. Also no primips, no AMA. Those things can risk out women in the Netherlands. I would like to see something like a 20 week consult with an OB, where a woman is seen and ” cleared” by the back up OB for home birth (my Australian friends who are cared for by midwives all have a consult at 20 weeks with an OB). Also something where if a woman wants to have a homebirth with a CNM, things like GBS testing and the glucose test are mandatory.

moto_librarian

But the Netherlands also discovered that perinatal mortality was higher for its midwives than for OBs, this despite the fact that OBs are caring for high risk patients. IiRC, perinatal mortality was 2X higher for midwives even in a hospital setting. To the nation’s credit, there is a major focus on determining why this is happening.

Amazed

I find it funny, in a creepy way, that in the USA, those who dwell in homebirth land, point at the Netherlands as an ideal everyone should aspire to while in the Netherlands itself, people are asking, “What is this shit going around here?” and work to bring their homebirth rates down – and it has started paying in reduced mortality already. Why should anyone aim for a second best?

Now, I know you’re against aspiring to this ideal. I’m just using your post to ask why people are trying to bring over something that its very users find problematic.

Petticoat Philosopher

I actually wasn’t aware of any of that but it’s interesting and it kind of makes everything make more sense. Because, yeah, even non-woo types tend to hold up the Netherlands as an example of how homebirth can be safe. And it seems undeniable that it is far more safe than it is here. But you honestly don’t need to be any kind of scientist or medical professional to deduce that homebirth can never be as safe as hospital birth. All you need to know is that things can go wrong very quickly in birth, even with no prior indicators of risk, and that medical interventions that only hospitals can provide might well be necessary in those circumstances. From there, it’s really just simple logic. But I’ve never been able to wrap my head around the apparent fact that the Dutch are quite happy with their system, in which homebirth is common. It makes a lot of sense that, actually, they’re not. At least not all of them. What accounts for the the popularity of home birth having endured this long, I wonder? In some European countries, it is standard for midwives to attend women in childbirth but they generally do it in hospitals.

I was always uneasy with the idea of homebirth but my friend’s experience with her first child made me think “absolutely no freaking way”–healthy 25-year-old woman, easy, uncomplicated pregnancy, but when it was go time, the umbilical cord ended up being knotted. That baby needed to come out pronto. She was at a birth center on the campus of a hospital being attended by a CNM and the proximity seems to have been quite sufficient to get her in for her C-section in time, as evidenced by the fact that her daughter is alive and healthy. Had my friend given birth at home, her baby would have almost certainly died an entirely preventable death. And there was no way anyone could have predicted it. It was just crazy luck but crazy luck happens and the consequences can be horrible.

And I also just don’t get the appeal. Like I said, I don’t want all that action in my home! One of the reasons I find staying in a hotel so relaxing is that it’s not your home so you don’t have any responsibility. I am sitting in my apartment right now thinking, “I should clean out that closet and my shower really could use a scrub before my mom visits this weekend.” I don’t want to have any kind of responsibility on my mind while giving birth except the responsibility to get this freaking human out of my body. And I am happy to leave all that mess elsewhere too. I have a Canadian friend who had 4 children at home (used to be a fundamentalist Christian) and I remember a story about a very short umbilical cord with one of them. As I recall, there was no danger involved but the story ended with cord blood splattered across her bedroom wall.

Yeah, I don’t want blood splattered on my wall. I am quite happy to have that be somebody else’s wall, thank you, specifically, a hospital’s. 😛

Homebirths have been steadily declining in the Netherlands, BTW. Where they constituted 30% of NSVDs two decades ago, I believe it’s down to about 10% now. Those who point to the Netherlans are almost always citing out-of-date statistics.

swbarnes2

Everyone can look at the CDC WONDER database and see how much worse OOH CNMs are versus in-hospital ones. That small fringe of CNMs are not getting results that are worth celebrating. Midwives in Morecambe Bay were about as well educated as American CNMs, putting them in charge of births didn’t go so hot.

Daleth

You understand, the way to make homebirth safer is to do fewer of them. That’s how every country that has better stats than the US does it. Tell more mothers “no homebirths for you, too risky”. Tell more mothers “your labor is not going perfectly, you need a hospital now”.

THIS, a hundred thousand times. That’s what “risking out protocols” means: some women will be told they cannot have a home birth because they’re at high risk of serious complications.

As athe amount of data increases, it becomes apparent that the quality of the midwife who delivers a woman at home is only ONE, albeit a major one, of the factors that cause homebirth to be more dangerous than hospital birth. By all means strictly regulate the education and practice standards of midwives; it would be a good start, and ideally, on a national level so a woman in any state would have confidence in the competence of her midwife (state regulation just means a bad midwife scuttles to a more lenient state), but it would only be a start. Better antenatal education of pregnant women– or even women only contemplating pregnancy — about the risks of homebirth is badly needed.

sdsures

“Better antenatal education of pregnant women– or even women only contemplating pregnancy — about the risks of homebirth is badly needed.”

Which this blog and Dr Amy’s new book are doing a fine job of.

Nick Sanders

And given that there women who DO decide that the increased risk of C-section & forceps

You’re loading the language. C-section is not a risk, forceps are not a risk. They may have risks associated with them, but so does getting an IV, taking a new medication, and even riding the elevator to the floor your doctor is on, but no one disparages hospitals for these things.

don’t we owe it them to make HB safer?

The things that make birth safer: good monitoring; increased sanitation; proper equipment, medicine, and an operating room all at arm’s reach; these cannot be provided in home.

MWguest

“Don’t we owe it to them to make HB safer?”

You know what? I’d really love to hear some homebirth midwives asking this question, and engaging in some real discussion about how to make that happen, instead of accusing hospitals of not being accommodating enough of their transfers.

But YES! there should be things done to homebirth safer, and those offering homebirth should be the ones spearheading that initiative, BUT, frankly, the CPMs (and DEMs, and a few wingnut CNMs) are the source of the poor outcomes in homebirth – and seemingly oblivious to that fact.

Who?

This is a very fair point. Them that broke it would be the ideal people to fix it.

I’ve delivered women in the home, when in the UK. The reality is that, even in a system which, in the 1970s, when the NHS maternity services were in much bettter shape than they are now, homebirth was NOT as safe as hospital birth, and I am convinced it can never be so. First of all, although rigorous vetting protocls can assure that only the lowest-possible risk women deliver at home, in cases of sudden severe fetal distress, hemorrhage, and/or malpresentation, and there is a specialized “flying squad” ambulance service can be easily summoned, TOO MUCH TIME IS LOST in transfer, You cannot compare the amount of time between summoning aid when at home and having an OR down the hall — and when the axe falls, it often falls extremely fast and the consequences can be literally a matter of life and death. It’s quite true that 80-85% of births can be performed by a five year old cretin; it’s that other 15-20%, and making a bad choice or decision is not like buying a baby gift in the wrong color.

The sooner NCB advocates begin to accept the fact that, while the majority of births are uncomplicated, not ALL are, and every mother and baby deserve the best technology, used appropriately and sensibly, will we make real progress. But instead they seem to be devoted to a dangerous fantasy, as if they find the truth somehow deeply intimidating.

Erin

The thing is, those “vetting protocols” only go so far because you can’t force women into giving birth in hospitals. I know of at least 3 women who are planning some variety of hbac in the UK, all of whom have multiple risk factors but because of their “birth rape”…they are opting out. One hasn’t even had any ante-natal checks whatsoever because she trusts her body, the others have had some but are refusing the things which they felt forced them into a section last time like glucose tolerance tests/blood pressure checks etc.
One of my friend’s elective C-section got knocked back six hours by a home birth transport gone wrong but stuff like that doesn’t matter. In fact said friend ended up on the ward with the women who delayed her section and once they discovered that, the woman felt she should be grateful as she’d been given more time to go into labour…the fact that my friend was carrying a breech baby with a family history of stuck babies was irrelevant.

Squillo

You know what? I’d really love to hear some homebirth midwives asking this question, and engaging in some real discussion about how to make that happen, instead of accusing hospitals of not being accommodating enough of their transfers.

This. A million times.

Daleth

And given that there women who DO decide that the increased risk of C-section & forceps associated with hosptial birth is one they don’t want to take one, don’t we owe it them to make HB safer?

If you need a c-section, the increased chance of getting one isn’t a “risk” but a BENEFIT. Ditto forceps, although like many women I would choose a c-section over forceps every time for two reasons:
(1) forceps have a not insignificant risk of injuring or killing the baby–my mother was permanently handicapped by forceps at her own birth; and
(2) forceps MASSIVELY increase the risk of severe, permanent pelvic floor damage in the mother.
C-sections don’t have either of those risks, so that would always be my choice.

So, the only thing that it makes sense to use the word “risk” about is the risk that, if you’re in a hospital, you might end up getting a c-section or forceps use that you/your baby did not need. But the thing is, if you’re laboring in the hospital and the doctor recommends a c-section or forceps (or anything else), you are free to refuse. Whether you think you don’t need one, or aren’t sure but just don’t want one, refusing it is your absolute right. Your doctor will tell you what the risks of refusing it are–legally and ethically, they have to do that so that your decision is the product of INFORMED consent–but the decision is yours to make.

So what, again, is the actual risk here? Getting a needed c-section is a benefit rather than a risk, and refusing a c-section that you think is unneeded or that you just don’t want is your right, so again, not something that’s going to happen if you refuse.* So WHAT IS THE RISK? Is it just that some women worry that if they’re in the hospital, the doctor might convince them to consent to a c-section in order to protect the baby?!

* I’ve only heard of *one* case in which a woman alleged that her doctor did a c-section despite her refusal to consent–it was a VBA2C that took a turn for the worse during labor, and allegedly the hospital’s lawyer told the doctor to go ahead in order to save the baby’s life–and that is, AFAIK, still being litigated so I don’t know what really happened.

Amazed

OT: Just coming over from Dr Amy’s Facebook page. The breastfeeding chicks there are in full gear. I actually pitied them. It must be terrible to be unable to love, nourish, nurture, and turn your kids into smart, responsible, well-rounded, cultured adults. It’s actually pitiful to think all the things that only human mothers can do meaningless and be able to only do the bare mammalian minumum.

Marie

I also find it difficult to take those people seriously when they end every sentence with “lol” and “k.”

“You keep using that word. I do not think it means what you think it means.”

Rach

Yes, why do they pepper all their comments with ‘lol’ whether humorous or not? It’s such an annoying affectation. I’ve noticed it among anti-vaxxers, homebirthers and lactivists. It’s like they need to show that they’re laughing at their opponents. Very high school.
Their pages must be unbearable to read (beyond the obvious reasons).

sdsures

Blonde bimbo reflex?

mostlyclueless

If any of you other nerds are interested, this page has a video of a debate from the ACOG annual meeting about routine elective induction at 39 weeks:

The title of the session is “http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Meeting/Educational-Program/Colloquia/Colloquia-Monday” and the first 10-15 minutes is another talk about reducing surgical site infections after c-sections.

Haelmoon

We are having a similar discussion at the SOGC this year in Vancouver. I am on a panel where we are addressing induction of labour. My summary point it “why is it ok to offer a C-section at 39 weeks, but I cannot offer an elective induction at the same gestational age”. I am not advocating recommending inductions, but I think our language about inductions it too black and white. I think that we need to have compelling medical reasons to recommend an induction. However, I think that we should be much more liberal in our discussion of pregnancy management at 39+ weeks – risks and benefits of conservative management, medical management (induction of labour) and C-section. All have risks, but also all have benefits. If we really want patient centred care, we should be offering the choices with appropriate discussions. I look forward to the discussions that follow!!

SarahSD

I don’t understand why it has to be an either/or situation. Yes, talk about the differences in safety between home and hospital birth, and work from those differences to improve homebirth for those who choose it. It sounds like the authors implicitly believe that there is no real “debate” to be had about the safety of homebirth, or they would not be concerned about improving safety and preventing bad outcomes.

As for “increasing the availability of physiologic birth in hospital”, I don’t think that there is necessarily anything wrong with giving women options to choose a less interventive birth in hospital. But if the myths around interventions are not being dispelled, and hospitals are just repackaging false NCB claims as a marketing tactic, they’re as complicit as the renegade midwives in denying or obfuscating informed consent.

guest

I feel like passing laws to prevent unvaccinated children from attending public schools IS basically saying “let’s see how we can make not vaccinating safer.” But it’s safer for the children who can’t be vaccinated, and the immunocompromised rather than the anti-vaxxers.

Allie P

“why are some obstetricians insisting”??? Am I missing something? From that list, the only person on there who even COULD be an Obstetrician (i.e., has an MD or DO) is Caughey.

The Bofa on the Sofa

Birth is empirically NOT “as safe as life gets.” Not, at least, until you are 92 or so…

Let me reiterate the plot from the post last week.

These are the facts. The day you are born is far and away the riskiest day of your life until you are very, very old.

Are you nuts

I’m pregnant and have a grandma who will be 91 when the baby is born. I find it very unsettling that Grandma and bebe have the same one-day survival expectancy (with no offense to Grandma)! It’s a really crazy way to think about it!

Who?

How lovely you still have your Grandma with you!

Are you nuts

Absolutely!

mostlyclueless

Great post, I agree there are a lot of parallels between the two movements, not the least of which includes the inaccurate appropriation of science to justify their positions.

I would extend the analogy a little bit, although not as elegantly as you would be able to, I’m sure. One of the leading arguments in both cases (anti-vaxx, anti-hospital birth) seems to be that the standard recommendation carries risk too: vaccine injuries happen; babies die in hospitals too.

I think in both cases it’s completely appropriate for medical professionals to admit that risk, but most importantly to agree to never stop working to make the standard recommendation safer — i.e., let’s AGREE with home birth advocates that preventable deaths/injuries happen in the hospital, too. Let’s AGREE with anti-vaxxers that preventable deaths/injuries happen as a result of vaccines, as well as not getting vaccinated.

Because the solution in both cases is NOT to turn and run in the opposite direction — away from hospital births, away from vaccines. The solution is to improve hospital birth and vaccine safety. You can improve home birth all you want, but you will never be able to do an emergency c-section or blood transfusion in your home. So the solution to the “risks” of the hospital is to improve hospital birth, not to run screaming in the opposite direction.

My life includes seat-belts, airbags, smoke detectors, carbon monoxide detectors, regular physicals, daily exercise, yearly vaccination of humans, yearly vaccinations of animals, a good relationship with a vet, brightly colored reflective clothing for walking in the evenings, a charged cell phone, a regularly maintained car, and multi-stage lock system for our one gun and the ammunition kept in a separate place.

I wear a helmet when riding animals and bikes, have never ridden a motorcycle, and will not jump out of a plane.

I don’t eat plants unless I am certain I know which plant it is. I know I am bad enough at mushroom ID that I stick to store-bought mushrooms.

In short: Life isn’t inherently safe. Neither is birth.

namaste863

I stay away from guns altogether. I’m a total klutz. I wouldn’t want to find out how those two factors interact.

The Bofa on the Sofa

That’s why I will never get a motorcycle.

My experience with bicycles in my life has taught me enough to know it’s not a good idea to put me on two wheels in a dangerous situation.

guest

And that’s why I don’t keep sharp knives in my home. It’s a little more time consuming to prepare meals with a dull knife, but I lose less of my fingers that way.

MI Dawn

Actually, statistically, you’re more likely to cut yourself with a dull knife. Don’t ask me how or why I know this….

niteseer

But, the biggest risk is if you start to prepare food with what you THINK is a dull knife, and it turns out that your husband sharpened them all last night and forgot to tell you. As I learned, from painful experience.

guest

Well, that’s why I’m not married!

guest

Except I don’t. I cut myself with sharp knives, but never dull ones. So I don’t care what the statistics say. (I’m pretty sure they just use that hoary one to sell you knives.)

Who?

I once gave myself a very nice sliced finger with the blade of my food processor as I was taking it apart.

Some of us should really not be allowed anything sharp. The house rule here is ‘no wine until all chopping is done and blades are washed up’. Sometimes it’s just easier and less messy that way.

sdsures

The only serious cut I’ve ever gotten, it left an impressive scar on my finger – was when I was washing what we call our “Fatal Attraction” knife in the sink. I forget what the official name for that big bugger is. Anybody know?

Rather stereotypically, I passed out. Normally, blood doesn’t bother me, but that one time, it did.

Nick Sanders

I’ve done culinary arts, and a small amount of professional kitchen work. Dull knives are absolutely more dangerous, because if the knife doesn’t cut whatever you are working on, you’re going to try to use more force, and that’ll cause the knife to slip. And slipping knives seem to have this desire to aim themselves straight at whoever is using them.

guest

I have no idea what’s more dangerous for a trained cook, but trust me: sharp knives cut me, dull knives don’t.

Petticoat Philosopher

It’s actually easier to control a well-sharpened knife and you have to apply less pressure to use it, which is safer if it slips. The few times I have cut myself in the kitchen, it has always been with a dull knife.

guest

The few times I have cut myself in the kitchen, it has always been with a sharp knife. It’s not the pressure that’s the problem, it’s when something sticks and then suddenly gives way.

Megan

The appropriate line should be ” ‘Natural’ birth is as safe as life before modern medicine and technology gets.”

demodocus

I wonder how long before the empowered ones will come to tell Dr. Amy she’s wrong.

Amy Tuteur, MD

Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com...
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